Standing Committee E

[Mr. John Maxton in the Chair]

Health and Social Care Bill

John Denham: On a point of order, Mr. Maxton. Further to my point of order on Tuesday morning, it might help the members of the Committee if I brought them up to date with discussions taking place through the usual channels regarding our sittings. It is intended that at or immediately before our rising at 11.25 am we should move to a meeting of the Programming Sub-Committee, at which it will be proposed that the Committee sit, if necessary, up to 7 pm this evening, and to set out the possibility of meeting at 4.30 pm on Monday. Those are the possible arrangements to deal with the extra amendments that we will discuss. If the Committee makes better progress, the arrangements will not be necessary. Clause 19 Abolition of NHS Tribunal

Clause 19 - Abolition of NHS Tribunal

Question proposed, That the clause stand part of the Bill.

John Denham: Clause 19 sets out the arrangements for the abolition of the NHS tribunal, which is an integral feature of the proposals in the NHS plan to modernise the way in which poorly performing primary care practitioners are dealt with. We want to make the system more effective, quicker and fairer, not only for patients, but for practitioners.
 I hope that you will bear with me, Mr. Maxton, if I put clause 19 in context by referring, at least in passing, to clauses 22 to 28, which are relevant. Taken together, the clauses update the provisions for managing health authority practitioner lists. Clauses 22, 25 and 27, which we will debate subsequently, deal with lists and cover doctors, dentists, pharmacists and optometrists. They relate to non-principals as well as principals, and to practitioners who operate under parts I or II of the National Health Service Act 1977. Clause 22 deals with part II principals by amending the existing powers on admission to health authority medical, dental, ophthalmic, pharmaceutical and dispensing doctor lists. Clause 25 extends the concept of health authority lists to non-principals, and clause 27 extends it to doctors and dentists who are part I practitioners. 
 I mention those three clauses to try to avoid some repetition. Between them, they apply the same principles and procedures to each list, with any variations simply being those needed by the circumstances of particular groups. Although the clauses may seem similar in structure, that is the design and purpose as the issues that underlie them are the same. 
 The lists will underpin health authority systems for managing primary care services and for improving quality. The clauses will improve the arrangements by: giving health authorities powers to suspend or remove practitioners from their lists; extending the arrangements into the new provisions for service delivery, such as personal medical services, under part I of the 1977 Act; giving health authorities powers to remove practitioners from their lists on grounds of unsuitability, as well as when they are prejudicial to the efficiency of the service or because of fraud; and giving practitioners rights of appeal to the Family Health Services Appeal Authority against decisions by their health authority to remove them from its list. The clauses also reconstitute the Family Health Services Appeal Authority so that it is fully independent of the Secretary of State, and by including provisions to ensure that the new system operates quickly and effectively to address any risks to patients or to the service and to deliver proportionate and fair outcomes to practitioners. 
 We will have the opportunity to discuss the detail of the arrangements as we consider each clause, but those clauses are very much part and parcel of the series of measures that we are discussing on clause 19, to which I shall now return. 
 Only a small number of practitioners are referred to the NHS tribunal. However, there have been some problems with the tribunal's operations. It has been in existence since 1911, and has been responsible for the suspension and removal of poorly performing practitioners from health authority lists, but the system is now outdated.

Philip Hammond: Does the Minister remember saying that
the tribunal has operated effectively, with the broad confidence of the national health service and the professions, during that period.—[Official Report, Standing Committee A, 20 May 1999; c. 881.] 
What has changed since 20 May 1999?

John Denham: At that time, I had been in my post for only about six months. Since then, we have had the opportunity to consider more closely several cases going through the pipeline in which general practitioners' performance has been found wanting, perhaps in the criminal courts or by the General Medical Council. I have had to ask myself why those cases had not been referred to the NHS tribunal or why it had apparently failed to act. My conclusion is that a significant number of health authorities have lost confidence in the arrangement and take the view that the tribunal's procedures are unable to deal quickly enough with practitioners who pose a danger to patients. That has led to a situation in which health authorities are reluctant to instigate proceedings, so the tribunal's case load is light, averaging as few as eight cases in recent years.

Philip Hammond: Surely the Minister is not suggesting that his predecessor as Minister of State at the Department of Health—now the Secretary of State for Health—overlooked such important matters when he was in the post. He would surely have had the forward-looking qualities needed to see precisely the problems that the Minister has identified.

John Denham: Mr right hon. Friend the Secretary of State for Health gives way to no right hon. or hon. Member, or to any member of the Government, in his determination to improve quality in health provision. He has led the way in campaigning for improvements, from the development of the first-class service that set out our quality agenda, to his consistent pressure for effective reforms of the regulatory system,
 As each year goes by, more information becomes available, giving Ministers greater opportunities to study individual cases. As a Government, we now believe that the obstacles to making the NHS tribunal work quickly and effectively for patients, and fairly for GPs, are so great as to make us try to find a better system. It causes me no embarrassment at all to say that I no longer take the same position that I set out with as Minister of State in 1999. As I have said, since then I have had the chance to consider some cases, not all of which are yet entirely in the public domain, that have convinced me that we need a better system. 
 Health authorities are sometimes reluctant to refer cases to the tribunal because they perceive its processes as slow and bureaucratic. It would be wrong to cite individuals or health authorities, but in two recent cases the first action against a practitioner was the commencement of criminal proceedings, rather than action by the health authority to seek the suspension or disqualification of the doctors concerned. In both cases, the health authority did not refer to the tribunal because it considered that quicker action would result from letting the criminal case proceed. That is not good enough. 
 We must give health authorities the right tools for the job if we expect them in future—as we do—to monitor practitioners' performance and standards of behaviour and to take action quickly when necessary. As I caught your eye earlier, Mr. Maxton, I will not go into detail of the later clauses again, but we intend to have a system for suspending or removing practitioners that is faster, more effective and fairer to practitioners and their patients. We propose to confer on health authorities new powers akin to those of employers to suspend and remove practitioners from their lists. That will remove the need for the NHS tribunal. 
 The NHS Confederation, representing NHS managers, has welcomed clause 19. There has been no public opposition to the abolition of the NHS tribunal from the General Practitioners Committee of the British Medical Association. We must of course not overlook the rights of practitioners. Future clauses will deal with rights of appeal against a decision to remove, or contingently remove, a practitioner from a list. A need will arise, consequent on the clause, for a properly constituted and independent Family Health Services Appeal Authority. Clause 28 provides for that.

Philip Hammond: Despite some effort, clause 19 defied amendment, which is why we are now debating clause stand part. The best argument against treating the matter in hand as an open and shut issue came from the Minister in Standing Committee A on 20 May 1999. When we discussed circumstances that could lead to the disqualification of practitioners, my hon. Friend the Member for Lichfield (Mr. Fabricant) and I raised several concerns about practitioners being deprived of their livelihoods. We asked for reassurances about the nature of the process that they would undergo.
 The Minister has told the Committee this morning that the NHS tribunal will be abolished, that instead health authorities will take its role, and that appeals will be referred to the Family Health Services Appeal Authority. I am sure that the Minister will correct me if my paraphrase is wrong. The problem is that the Minister is adding nothing, but only removing a part of the current process. He told Standing Committee A, in response to an intervention by another hon. Member: 
 Concerns were expressed about whether we might be seeing the evolution of the tribunal into an arbitrary kangaroo court sitting in judgment over general practitioners. I had been trying to say that a case would reach the tribunal only after, for instance, internal health authority disciplinary arrangements had begun, or following measures to support and bring up to standard poorly performing doctors.—[Official Report, Standing Committee A, 20 May 1999; c. 882.] 
The Minister argued that the present safeguard is the initial informal involvement of health authorities in difficult situations, with referral to the tribunal happening only later. In answer to a question from me about the nature of the tribunal and the guarantees and safeguards, the Minister said—and perhaps the reason that I am repeating these points is that I have a long memory— 
 I honestly think that the hon. Gentleman is making a ridiculous meal out of this. Given the track record of the tribunal and its status as an independent body—the Secretary of State has no influence over its quasi-legal, quasi-judicial hearings—as well as the seriousness of the offences that it has heard, I cannot foresee any circumstances in which it could be used in the way that the hon. Gentleman suggests. —[Official Report, Standing Committee A, 20 May 1999; c. 890.] 
That was a response to concerns about the human rights implications of people being deprived of their livelihoods by a tribunal decision. 
 The Minister now proposes that health authorities should take the decision, subject, of course, to an appeal to the FHSAA. Health authorities are not quasi-legal, quasi-judicial hearings, over which the Secretary of State has no influence. The Secretary of State has great influence: indeed, he has power to direct health authorities. They cannot be regarded as impartial bodies. The Minister's proposal would remove from the process any quasi-judicial function at first instance. I accept that there will be a quasi-judicial body, the FHSAA, as an appeal mechanism. However, in the first instance, such matters will be dealt with by a non-independent, non-quasi-judicial body. That is important because previously the Minister outlined a mechanism of cases going first to the health authority as an informal, non-judicial body, then to the tribunal and finally to appeal. Now, we have just two steps: cases will go first to the health authority and then—and only if there is an appeal—quasi-judicial involvement. 
 Section 47 of the 1977 Act, which was inserted into that Act by the Health Act 1999, provides for a health authority to ask the tribunal to review a conditional disqualification. There are several provisions of that nature, but I will take that one as an example. Section 47 states, 
If any health authority request a review of a conditional disqualification on the ground that 
—and then lists a number of grounds— 
the tribunal shall review the conditional disqualification. 
What will happen now? Will the health authority request itself to review a conditional disqualification that it has made? That is not a sound process. Has the Government thought through the consequences of abolishing the tribunal? Can the Minister tell us how the mechanism will work when health authorities are effectively subsuming their roles and those of the tribunal under the existing system? Will the Minister confirm whether it is the case that sections 46 to 49 of the 1977 Act are to be repealed by schedule 5? Will clause 19 be necessary because, if sections 46 to 49 are repealed, the national health service tribunal will no longer exist or be referred to in the extant legislation? Clause 63 and schedule 5 will have the same effect. The principal of parliamentary drafting is economy and on that basis clause 19 may be redundant. 
 Can the Minister tell us what the position is in Scotland? The legislation includes reference to the NHS tribunal in Scotland; is that tribunal different from the one we are discussing; is it constituted under a different Act, but has the same name? Will that tribunal continue to function? Will it be affected by the Bill? Can the Minister assure the Committee that he dealt in his opening remarks with all the current functions of the NHS tribunal and how they will be handled in future? Can he also assure us that the NHS tribunal has no functions other than the ones he has referred to in relation to the qualification and disqualification of medical practitioners? If there are any other functions, can he tell us who will be responsible for them and how they will be handled?

John Denham: I shall address those points hopefully in order.
 I have already dealt with the way in which Government thinking has moved on since the debates in July 1999. As far as I can recall, the assurances given on how the 1999 legislation would operate were correct at the time and remain correct in respect of the legislation. We now propose further changes to the legal framework, which I explained this morning. 
 Some feel that in politics the worst thing that Ministers can do is to change their thinking on an issue. Such people attach the highest premium to sticking to a position. However, I believe that if a Minister gains a new insight or a new understanding of where problems may lie, it is perfectly proper for him to bring it to bear on future policy. That is what we doing now. 
 I am not sure whether it is appropriate to go into detail during a clause stand part debate on how the new procedures will operate, especially as we shall be discussing that in relation to other clauses. I have signed the declaration that, in my judgment, the measures in the Bill are compatible with human rights requirements. Although, under our proposals, the ability to suspend or disqualify will pass to the health authority, it will not have escaped the notice of the hon. Member for Runnymede and Weybridge (Mr. Hammond) that we are reconstituting the Family Health Services Appeal Authority so that it is no longer a body of the Secretary of State; otherwise, it would not have had the independence necessary to meet the requirements of the Human Rights Act 1998. 
 I believe that we are taking the necessary measures to ensure the proper procedures. For instance, we shall be discussing in later clauses whether suspension would affect the human rights of practitioners, and I am sure that we shall consider maintenance of income in such circumstances. We have studied what is necessary to make the Bill compatible with human rights legislation.

Philip Hammond: I accept what the Minister says, which is why the final court of appeal will be quasi-judicial. I want to focus on what might be called the court of first instance. Will the health authority's informal role, which the Minister outlined during our debates on the 1999 Act, be clearly and distinctly separate from its formal role in disqualifying practitioners? Will a formal hearing procedure have to take place, and will that be quasi-judicial—will a burden of proof be required at that stage, or will the whole process be informal until the point when an appeal is lodged to the FHSAA?

John Denham: The hon. Gentleman will be aware that future clauses provide for the ability to make regulations on how the health authority should conduct that process. For example, the Bill makes it clear that we shall set out the criteria that health authorities must take into account when considering whether to suspend or disqualify a practitioner. That implies that a process has to be followed, and that the health authority would have to demonstrate that it had done so in order to comply with the legislation. The process will include written notification and the opportunity for a hearing. There will not be a slide from general performance management into taking practitioners off the list; there will always be a point at which the practitioner will know that the process is taking place. It is worth re-emphasising that the provision is part of a wider picture and that it should give health authorities better informal powers.
 A few weeks ago, we announced the formation of the National Clinical Assessment Authority, a body to which health authorities could informally refer GPs if they had doubts about their performance or assessment. Since July 1999, we have moved to strengthen the early intervention powers available to health authorities if they were concerned about doctors' practices. 
 The hon. Gentleman asked other specific questions. The Bill does not abolish the NHS tribunal for Scotland; the NHS tribunal will continue to operate there. It is a matter for the Scottish Parliament. We shall be discussing later the arrangements between England, Wales and Scotland, to ensure that practitioners who are not on the list in one country are not on the list in the others. 
 I hope that I have answered all the points raised by the hon. Member for Runnymede and Weybridge, if only briefly. 
 Question put and agreed to. 
 Clause 19 ordered to stand part of the Bill.

Clause 20 - Payments relating to past performance

Philip Hammond: I beg to move amendment No. 178, in page 14, line 6, leave out from `shall' to end of line 7 and add:
`be substituted with—
(4) The remuneration to be paid under the arrangements mentioned in subsection (1) above to a practitioner who provides general medical services shall, at least in part be dependent upon the quality and outcome of the services provided and shall not ordinarily consist wholly or mainly of a fixed salary.'.
 The clause is four lines long instead of one, so it lent itself to amendment. It is designed to repeal the requirement that general medical services remuneration should not consist wholly or mainly of a fixed salary paid to the practitioner. 
 When the 1977 Act was written, or when this provision was inserted, the assumption was that the basis of such remuneration would be capitation—that practitioners would be paid a sum per person on their list. The Government's policy is clearly to move away from capitation payments, and broadly speaking we would support that policy. It can provide a perverse incentive to practitioners to get the largest list they possibly can in order to maximise remuneration. A high number of patients on a practitioner's list does not necessarily correlate with a high quality of care provided by that practitioner. There might be prima facie reasons for assuming that the larger the practitioner's list, the lower the quality of the care that he is able to provide. 
 We understand the Government's desire to allow practitioners to be remunerated by reference to quality and outcomes, rather than simply by reference to the number of patients on their list. However, the clause is not necessary to achieve that objective. I refer the Committee to the explanatory notes, which state: 
 Clause 20 ends the requirement under 29(4) of the 1977 Act that the majority of remuneration of GPs should have reference to the number of patients the GP has undertaken to provide services under General Medical Services. 
That is not what section 29(4) of the 1977 Act states. This is not the first time that I have found the explanatory notes to be misleading, so that a member of the Committee who does not have time to read the base legislation may be misled. 
 Section 29(4) of the 1977 Act states: 
 The remuneration...shall not...consist wholly or mainly of a fixed salary 
that does not relate to capitation. It does not state that the remuneration cannot be calculated with reference to some other criteria such as quality or outcomes. The notes are misleading, and might lead somebody to believe that clause 20 was required in order to allow the Government to introduce remuneration based wholly or mainly on quality of outcomes into the GMS contract. That is not the case. It is already possible to introduce remuneration based on such criteria. 
 The amendment specifically includes a reference to quality and outcomes. It requires consideration to be given to those factors as a basis of remuneration. To allow remuneration to be based either wholly on capitation, or wholly on a fixed salary, would be a step backwards. Everything that the Government have said suggests that they want to move away from capitation-based payments to ensure that quality of patient experience and outcomes are the principle criteria in determining the remuneration of a practitioner. Clause 20 would allow practitioners to be paid a fixed salary. It removes from the 1977 Act the prohibition on fixed salaries without reference to capitation, which is neither positive nor helpful and flies in the face of the Government's stated objectives. 
 I am unsure what is in the Government's mind. Members of the Committee will be familiar with the distinction between personal medical services and general medical services. Under personal medical services, practitioners are paid a salary, while under general medical services, they are remunerated in a variety of ways, though with capitation as a significant element of the package. 
 During the debates on the Health Act 1999, which introduced personal medical services, the Minister assured the Committee that personal medical services would co-exist alongside general medical services. They would not replace them and there would be no pressure to move from GMS to PMS. Despite the assurances, some GPs are—or will be—under pressure to move from GMS to PMS, particularly single-handed practitioners, and that flies in the face of the assurances given in 1999. 
 The clause—and its ramifications—suggests that the Government, in addition to a full-frontal assault on GMS—to persuade, entice and cajole practitioners into PMS—are working a flanking movement. They are undermining the principals of GMS by giving themselves the power to make a fixed salary the basis of a GMS service contract, which would give it most if not all the characteristics of a PMS contract. Perhaps the Minister can explain what the distinction between GMS and PMS will be? Perhaps he will give an assurance that, even if the clause is passed without the benefit of the amendment, there will still be a distinctive GMS system. 
 If the Government have a benign reason, such as the one that they gave in ``The NHS Plan'' and other documents, for wanting to re-negotiate the GMS to make it more quality sensitive, they will have no difficulty accepting the amendment. The Minister should either accept the amendment or admit that the Government have a plan to out-flank GMS with a fixed salary system that will make it almost indistinguishable from PMS.

John Maxton: Before I call the Minister, perhaps it would be for the convenience of the Committee if I said that I have changed the provisional selection to include the debate on clause stand part in the debate on the amendment.

John Denham: I am pleased by the widespread acceptance that the GMS contract based primarily on head counts, has had its day. That is the view outside the Committee and is generally the view of the hon. Member for Runnymede and Weybridge. The way forward is to move towards contracts that recognise the quality of service that GPs provide and reward them appropriately. The measure will not abolish the link between pay and patient numbers: it will merely remove the legal requirement for the majority of GPs' pay to be linked to patient numbers. As has been pointed out, in extreme cases, a direct link between list size and pay can lead to a perverse incentive, particularly for hard-pressed GPs.

Philip Hammond: I must ask the Minister to correct what he said. Despite what the explanatory notes state, my interpretation of section 29(4) of the 1977 Act is not that it requires the majority of remuneration to be linked to capitation, but that it requires it not to be a fixed salary that is not linked to capitation. That is different. My reading of the section is that it would permit the Government to use a criterion other than capitation for the majority of remuneration. That would include outcomes and quality. That is why the clause is not needed to enable the Government to do what they intend.

John Denham: My advice and understanding are that the practical interpretation of section 29(4) is that more than 50 per cent. of GPs' interests must be calculated on the basis of the number of patients on a list. I shall seek advice about that again, after the Committee, and if my interpretation is wrong I shall write to the hon. Gentleman to correct what I have said. I believe that what I have said is the general understanding, and it is what we are attempting to deal with, to bring about greater flexibility in the development of the GP contract in future.
 The fixed salary is the fixed basic income of the GP rather than specific additional payments. I should make that clear, because I suppose that it is possible for more than 50 per cent. of total income to come from other sources. We are concerned with the basic income of a GP. Immunisation service payments would fall outside the calculations that I am describing, for example. We want to work with the British Medical Association to modernise GP contracts. We are going about that now and the clause would remove a constraint. 
 The hon. Member for Runnymede and Weybridge raised two issues in addition to the interpretation of the 1977 Act. The first was whether the Bill should include a new requirement with respect to outcomes and quality. The second was whether the clause leads to blurring, changing or redefining of the boundary between PMS and GMS or perhaps whether there is a relationship between that boundary and salaried or independent contractor status. 
 I have thought long and hard about amendment. No. 178. We certainly want a future contract to reflect quality and outcomes much more clearly than the national contract does now. I am not convinced, however, that it is necessarily helpful for the Bill to replace a constraint that has been and will be problematic with a different constraint. The difficulty is illustrated by the amendment, which could allow the quality consideration to be attached to the merest fraction of the payments made to GPs operating under the Red Book arrangement. We accept the spirit of the relevant part of the amendment and have acted accordingly in the NHS plan. There is a consensus on the need for more emphasis on quality and outcomes. 
 In response to the hon. Gentleman's request for me to clarify as well as I can the difference between PMS and GMS, I remind the Committee that PMS is a voluntary contract entered into by GPs at local level. About 22 per cent. of GPs indicated their desire to go onto PMS contracts from 1 April 2001.

Philip Hammond: As the Minister has made that comment, would he reiterate for the record what I think he said in 1999, that PMS will remain voluntary and that GPs, whether single-handed or otherwise, will not to be subjected to pressure to enter into PMS arrangements in future?

John Denham: GPs are not being pressured into PMS arrangements, although I need to be clear that we said in ``The NHS Plan'' that our preference is for single-handed GPs to have a different national contract that would overcome their apparent problems of clinical isolation. Should that not be the case, we would seek to move that group of GPs onto a national PMS contract. That is important and the hon. Gentleman is right to ask me to reiterate.

Philip Hammond: Just to clarify, is the Minister saying that he hopes to be able to negotiate a new type of GMS contract for single-handed practitioners, but if he is unable to negotiate that to his satisfaction, he will consider imposing a PMS contract on single-handed practitioners? Negotiations that take place under the threat of imposed unilateral action are not usually fair or reasonable.

John Denham: The hon. Gentleman is entitled to his view, but our intention is to negotiate an appropriate national contract that can help overcome recognised problems faced by single-handed GPS. The hon. Member for Woodspring (Dr. Fox) has set out the need to address some of the problems of physical isolation that are faced by single-handed GPs. There is not a huge difference on this issue across the Committee. The essential difference between PMS and GMS contracts is the same as that between the locally-agreed contract which GPs enter voluntarily and the national contract that is for the majority a matter of choice, but is the default national contract under which GPs operate. The clause was not intended to change that basic difference between the national Red Book contract and the local PMS contract, nor is there any intent behind the clause, or in wider Government policy, to force people from independent contractor status into a salaried status. That is important and it is now widely accepted.
 There is often confusion, and a belief that PMS means a move to salaried doctor status. It is worth saying on record again that the vast majority of GPs with PMS contracts are independent contractor status GPs. They have not switched to salaried status: they have changed the nature of their independent contract. I do not see why there should be significant changes other than those that are taking place at grass roots where it appears that a rising number of younger GPs are opting for salaried status. It is too early to tell, however, whether they see that as a permanent arrangement or something for the first years of their practice, taking on the greater obligations of independent contractor status later. From the people I have talked to, it appears that salaried status is seen as transitional. However, essentially that is something permitted by the greater variety of employment opportunities available to GPs.

Peter Brand: The Minister said that PMS was a voluntary arrangement and clearly that is the case in respect of the move from GMS to PMS. Could the Minister reassure us that the reverse move is also possible? Once people have accepted PMS, if there were to be a disagreement with the commissioning body, under PMS the same health authority would also have the power to block the institution of a GMS contract.

John Denham: Yes. I do not have chapter and verse at my fingertips, but my understanding is that PMS GPs have a preferred status in their ability to switch to GMS that would not be available to another GP who wanted to work on a GMS basis. I assure the hon. Gentleman that nothing in the measures that we are taking will change that status, which, as I recall, derives from the National Health Service (Primary Care) Act 1997.

Doug Naysmith: Will my hon. Friend the Minister confirm that it will still be possible for single-handed practitioners to remain under GMS conditions of service, provided that all the problems of isolation and the necessities of keeping up with clinical development are dealt with?

John Denham: We would like to negotiate a new national contract with a greater emphasis on quality that could therefore address such issues. We can never say at this stage whether negotiations will be successful, but the NHS plan makes it clear that we would like to tackle such concerns through a quality-based national contract. That is what we shall seek to do with the profession and its representatives.

Philip Hammond: I want to focus on one point. I am not sure that the Government have made or would want to make a case for paying fixed salaries. The case for paying GPs by reference to the quality of outcomes, the experience of their patients and the quality of service provided does not need making, as it is self-evidently sensible. The Minister rather glibly glossed over my concern about the need for the clause at all. I re-assert the fact that section 29(4) of the 1977 Act does not prevent the Government from negotiating a GMS contract in which the majority of the payment would refer to quality of outcome, patient experience, clinical indicators and anything, in fact, other than a fixed salary amount. The only reason for the clause would be if the Government intended to pay GPs the majority of their remuneration—50 per cent. plus of it—by a fixed salary. I have not understood from the Minister's remarks whether that is his intention.
 The Minister said that the amendment could allow for only 1 per cent. of GPs' remuneration to be linked to quality, while 99 per cent. was linked to something else. That is true, but the amendment makes it clear that no more than half the remuneration would have to be based on a fixed salary. It uses the same language as the 1977 Act, which the Minister has interpreted as meaning no more than half. The amendment would provide that only less than half of the remuneration could be through fixed salary, and that at least some of the remuneration must refer to the quality and outcome of services provided. That is a clearer presentation of what the Minister seems to be saying that he wants to do. 
 By rejecting the amendment, the Minister leaves us with the suspicion that he intends more than 50 per cent. of remuneration being paid by way of a fixed salary and, by extrapolation, less than 50 per cent. being related to quality or other parameters that we all might consider to be sensible and useful. Will he clarify his intention? Why can he not accept the amendment? The mere fact that it does not require a minimum percentage to be linked to quality does not invalidate there being a reference to quality and outcome in the Bill. The clause, unamended, would allow payments to be made without reference to the quality or outcome of the services provided. If the Bill is to give effect to the Government's stated intentions, it should include a reference to quality.

John Denham: I have considered that last point carefully. It is a matter of judgment for the Committee, but my view, on balance, is that quality need not be included. The Government's wish to have a contract that gives appropriate rewards for quality is shared by the profession. That is not in doubt. We have found in previous legislation that including such factors imposes constraints; it is a matter of judgment whether one should impose a further constraint, but I believe that it is unnecessary.
 The hon. Gentleman is in something of a tangle with his interpretation of clause 20 and the 1977 Act. The effective interpretation of the 1977 Act has been that doctors are paid a fixed amount each year, including a sum that is based on capitation and must be more than 50 per cent. of the total remuneration. That is a restriction. The contract is to be renegotiated. I do not know whether a payment related to quality might replace it. It is conceivable that, as with some PMS contracts, a certain part of the payment should relate to maintaining a certain size of list, but one that is not related to capitation. A number of variations are possible. 
 Rightly or wrongly, I take reassurance from the fact that my officials have met with the General Practitioners Committee of the BMA and discussed the clause in some detail, as they have done the rest of the Bill. The GPC understands what we propose, and does not share the hon. Gentleman's concern. It is true that they would like a provision on quality to be included in the Bill, which I entirely understand. However, it has not raised with my officials the matter of remuneration being 
wholly or mainly of a fixed salary.

Philip Hammond: I do not wish to flatter him unduly, but the Minister says that the GPC has not raised those concerns with him. If he turns his mind back a couple of years, he may remember that, on more than one occasion, he got the better of the GPC in negotiations. The fact that the GPC has not expressed concerns about what the Minister intends to do does not mean that we should not probe the matter carefully. By nature, doctors tend to be trusting, and they will expect Ministers to be open and honest. I do not think that there is any misunderstanding over clause 4.
 I seek a clear statement from the Minister. If he is looking to replace capitation-based remuneration with fixed remuneration, he needs to repeal section 29(4) of the 1977 Act. If he proposes that GPs should have more than 50 per cent. of their remuneration by way of a fixed salary, without reference to capitation or anything else, he needs clause 20. My understanding, from the general tone of the Government's approach to GP remuneration, was that he intends that more than 50 per cent. of GPs' remuneration should be related to the quality of the service that they provide and the outcomes that they deliver. If, therefore, the most significant part of their remuneration will be dependent on the quality of service that they deliver, he does not need clause 20. 
 Nothing in section 29(4) of the 1977 Act would prevent the Minister from paying a general practitioner 49 per cent. of his total remuneration as a fixed sum, by reference to nothing, and the other 51 per cent. by reference to something like quality of outcome or patients' experiences of the services delivered. Will the renegotiated GMS contract provide for the payment of a fixed salary, without reference to capitation, which constitutes more than 50 per cent. of the total remuneration? If so, the Government are missing an opportunity to do something that their propaganda suggested they would do, which is to place quality patient experience and outcomes at the top of the agenda.

John Denham: In a sense, capitation payments are fixed. They are not fixed in absolute terms, because they depend on the number of people on the practitioner's list, but they are fixed in that they must be more than 50 per cent. of the total. We are trying to remove that obstacle. The provision effectively requires a GP who has twice the number of people registered on his or her list as another GP to be paid twice as much. We are trying to escape the hook of a direct link to capitation. In the future, it is likely that remuneration will be linked less directly to the number of patients on the list. In some PMS contracts, the GP is required to maintain a list of a certain size, but the contract emphasises the quality of services provided to those on the list. It is conceivable that we may wish to cap that type of contract.
 In this discussion, where there is no real difference between our objectives and those of the profession, it seems pointless to try to specify what elements might or might not constitute precisely 50 per cent. of the future remuneration. When we come to negotiate, it is likely that the number of patients will be a relevant factor, but we are trying to get rid of the provision that has effectively tied us to a capitation system.

Peter Brand: It is true that before quality can be delivered, a basic practice must be assembled, so there is still a need for a basic practice allowance of some sort. I support what the Government are trying to do, and that is not necessarily because I am so trusting. I have spent my clinical professional life with drug addicts—people who are pathological liars.

Philip Hammond: Like politicians.

Peter Brand: I have been anticipated. Medical negotiators can certainly cope with the average politician.

John Denham: We know that, but what we want to know is what the hon. Gentleman did before he became a Member of Parliament.
 We have reached the stage in the debate where I have set out my view of the legislation and the purposes that lie behind the clause, and the hon. Gentleman has set out his views. I fear that we will simply go over the same ground again and again.

Philip Hammond: I fail to be convinced by the Minister's argument. My interpretation of section 29(4) of the 1977 Act is that it would allow for a fixed salary, without reference to capitation, equivalent to 49 per cent. of the total remuneration to be paid. I see nothing in clause 20 that would stop a further amount, linked to capitation, being paid, and a further amount beyond that, linked to the fulfilment of other criteria.
 The Minister is clearly basing his remarks on the advice that he has been given. I will go away and talk to people who are better able to dissect these things than I am. I do not pretend to be a lawyer. One of the problems under which we labour in this place is that we are expected to provide interpretations and advice for which people outside the House would expect to be paid a great deal more per hour than Members of Parliament or civil servants are. However, I hope that the Minister will think again if I come back to him, before the Bill is considered on Report, with an opinion that gives credence to what I am saying. We are simply seeking to look behind what he is trying to do and find out whether he has an agenda that requires the measure. Such an agenda might give some cause for concern, whereas his stated agenda, which we do not believe requires the clause, does not. We accept that that agenda is being discussed with the profession. Our only concern is to unmask any actual or potential hidden agenda for the future. 
 The Committee can move on now, but I hope to revisit the issue with the Minister later. I beg to ask leave to withdraw the amendment. 
 Amendment, by leave, withdrawn. 
 Clause 20 ordered to stand part of the Bill.

Clause 21 - out of hours medical services

Desmond Swayne: I beg to move amendment No. 168, in page 14, line 21, leave out `another' and insert `any other'.

John Maxton: With this it will be convenient to take amendment No. 169, in page 14, line 26, at end insert
`, including requirements as to the provision of information on services provided to the principal'.

Desmond Swayne: In view of what the Minister has told us about the disagreeable consequences of reconvening the dreaded Programming Sub-Committee, it may be for the convenience and relief of the Committee if I kept my remarks as focused as possible. That will be my endeavour.
 Amendment No. 168 attempts to remedy the lack of clarity in the clause. What was meant was not entirely clear to us. The explanatory notes state: 
 The body to be regulated is any body or organisation providing out-of-hours cover to GPs that will have to be accredited by a Health Authority. 
Does that mean that the body will have to be accredited by any health authority, not necessarily by every health authority, to which it provides an out-of-hours service? That is our understanding of what the clause means, so we are trying to make it more explicit. After all, we are here to help. The spirit of the amendment follows Oliver Cromwell when he said that no real reform could be achieved unless the whole law was reduced to the bigness of a pocket book, intelligible to all men. 
 Having said that, and believing that the clause has precisely that meaning, I understand the attractions of its having an interpretation under which a provider would have to be accredited and be on the list of every health authority to which it provided a service. If a complaint were to arise against such a provider, the health authority that received the complaint might be unable to seek redress by taking proceedings against that provider, with a view to removing it from its list. The health authority would have to initiate those proceedings with another health authority that had the provider on its list. 
 It may be administratively convenient for a provider to be on every health authority's list to which it makes provision. However, that administrative convenience must be set against the huge bureaucratic burden that would be placed on the provider of having to register to be accredited by every health authority to which it provided a service. We tabled the amendment in the understanding that the clause means that once a provider has secured access to the system by gaining accreditation from a health authority, that body can provide those services to all health authorities. We seek to make that explicit in the Bill. 
 Amendment No. 169 is intended to make one of our principal concerns explicit. We fear that access to NHS services may be becoming fragmented. That concern for continuity of care is not restricted to Conservative Members, but is also a concern among medical professionals. In an article in Doctor on 21 January 2000, Dr. Gillam, the Luton general practitioner who is also a director of the primary care programme at the King's Fund, commented that NHS Direct was part of what he saw as an agenda of fragmenting access to the national health service and that it could destroy continuity of care. 
 That fear has been echoed in a survey of doctors published in GP Magazine on 25 February 2000, which revealed that 81 per cent. of doctors questioned felt that continuity of care was being jeopardised by NHS Direct and walk-in centres. That concern for continuity of care was expressed in the independent report that was commissioned by the Department of Health ``Raising New Standards for Patients—New Partnerships in Out-of-Hours Care.'' I draw the Committee's attention specifically to recommendation 4 of that report, which states that 
all providers should report all out-of-hours consultations to GPs by 9.00 am the next normal working day. 
Clearly, the authors of the report share the concern that there should be continuity of care and that that information should be provided. However, even that was only an interim measure and very much a second best, because the ideal solution is the provision of electronic systems. The electronic health record will provide a three-way exchange of data between NHS Direct, the out-of-hours providers and general practitioners. It would assist us if the Minister could say precisely what stage has been reached in the provision of the electronic record and what prospect there is of its delivery in the medium term. 
 I have a wider concern about the clause, which is not germane to these two rather focused amendments. I am inclined to leave that matter to a stand part debate, but if you decide that there will not be a stand part debate, Mr. Maxton, I shall seek to catch your eye a second time.

John Denham: The hon. Member for New Forest, West (Mr. Swayne) has raised some useful points and I hope that I can deal clearly with our policy intentions. We shall address these matters in regulations made under the clause, but what we intend to do on health authority accreditation goes some way towards meeting the hon. Gentleman's concerns, although not entirely.
 If a GP co-op provides out-of-hours services covering two or three health authority areas, it is obviously sensible for the health authorities to agree that one health authority should take responsibility for accrediting the service for all of the others, to avoid repetition of a bureaucratic process, and regulations will provide for that. However, we do not think it appropriate that an out-of-hours provider who is on the list of one health authority should automatically have that accreditation accepted by all other health authorities. The reason is that some out-of-hours providers are very large--some are large commercial organisations. Although legally they are single bodies, they have a fairly loose federal structure, and the quality of service can vary from one part of the country to another, even though the umbrella organisation is the same. 
 Thus we feel it necessary to allow a health authority, if it wishes, to choose to accredit the organisation that offers the service to patients in its area. We believe that to be the right compromise. Under these arrangements, part of a large organisation—I do not want to single out the commercial deputising organisations—would not receive an automatic right to accreditation everywhere simply because it offered a perfectly satisfactory service in one place, as quality of service varies.

Philip Hammond: I understand what the Minister says, but as the clause is phrased, it is the person providing the service—that is, the company—that is being accredited. The health authority would therefore be unable to determine who was providing the services. It could be a national company based in London that provided services all over the country.

John Denham: The health authority would be able to look at the arrangements being implemented in that particular area—for example, to satisfy itself that the information technology requirements or the arrangements for clinical audit were in place for patients in its area.

Peter Brand: Has the Minister considered an alternative way of tackling this problem? If approval in one health authority qualified a large company to practise in any other, it could lose that approval in all health authorities if its performance was unsatisfactory in any one of them. In some franchising operations, those who trade on well-known national images may not be diligent in ensuring that that national package is being delivered locally. That would make the larger organisations more accountable.

John Denham: The hon. Gentleman is right about accountability. Our solution allows the individual health authority to carry out the accreditation process itself. That will provide a stronger safeguard than the health authority having to accept the accreditation of other authorities and being able to object only once problems came to light. I think that we are at one on the level of accountability required.
 We entirely accept the principle behind amendment No. 169, but it should be dealt with in regulations. It is important that a patient's GP or a person providing personal medical services has full and up-to-date information when one of his patients has been seen out-of-hours—information on who saw the patient, the diagnosis, what was prescribed and so on. The out-of-hours review recognised that. The Government intend to specify that out-of-hours service providers must supply full clinical details of consultations to practices by the start of the next working day. We will make regulations to ensure that GMS principals and other providers of primary care receive the necessary information.

Philip Hammond: If the Minister is committed to ensuring continuity of care and that information is passed back to the principal practitioner, what arrangements will he put in place to ensure that the details of a patient's walk-in consultation is reported back to his GP?

John Denham: It is a consistent part of the walk-in centre programme to develop and improve those links. That relates to the electronic patient record, which the hon. Member for New Forest, West mentioned. Paragraph 4.21 of the NHS plan states that there should be
access to electronic personal medical records for patients by 2004. 
By that time, we expect that 
75 per cent. of hospitals and 50 per cent. of primary and community trusts will have implemented electronic patient record systems. 
That is the extent of the progress that the Government hope to have made by 2004. 
 In the interim, it is not sufficient for walk-in centres to wait for electronic patient records to come along at some time in the future. Depending on the local infrastructure, local protocols are being developed with primary care groups to use electronic communications, fax or telephone, as appropriate.

Philip Hammond: What would happen if a patient walked into a walk-in centre and refused to disclose his identity? My understanding is that the patient would receive a consultation like any other patient, although it would not be possible to report back, whether or not there is an electronic data system. That would be a serious disruption to continuity of care. If the Minister is concerned about the issue in relation to out-of-hours treatment, is he not also concerned about the proliferation of walk-in centres leading to patients being able to opt part of their medical history out of their records? That is happening in some walk-in centres.

John Denham: Every effort is made not only to encourage patients to identify themselves at walk-in centres, but proactively to encourage patients who are not registered with a GP to do so. I am not entirely sure whether the hon. Gentleman was suggesting that those who, for whatever reason, do not want to disclose their medical histories should be turned away from NHS treatment. However, we are working hard to ensure that continuity of care is maintained. That is a key objective in our development of this new and convenient method of access to the NHS.

Peter Brand: I am sure that we have a long way to go on information exchange, as a recent Which report pointed out. Would the Minister answer the question asked by the hon. Member for Runnymede and Weybridge slightly differently? If a patient registers normally at a walk-in centre but specifies that certain aspects of the consultation should not be shared, does that patient have the right to have those details withheld? The answer to that question will clearly be relevant to later debates.

John Denham: I should like to take advice on that, as that is slightly outside the scope of the amendments, which are about out-of-hours services provided by GPs or walk-in centres if they are part of an accredited system of out-of-hours services. I am not entirely sure of the precise legal rights that patients may have, in any part of the NHS, not to disclose their full medical history if they prefer not to do so. I would like to be sure before saying how that would apply to walk-in centres or out-of-hours services.

Peter Brand: It would help if that advice was made available in time for our later debates. It is not uncommon for a patient to share all sorts of information, and a core of information certainly needs to be shared, but a patient may not want to share certain aspects of a consultation. For instance, a pregnant under-age girl may not want a family friend who happens to be the GP to have that information shared. It is important, when we reach the information-sharing provisions, that we recognise that there are real ethical problems as well as administrative problems.

John Denham: I am grateful to the hon. Gentleman for that early indication. I hope that the Committee accepts that it is better for me not to risk misleading the Committee on those legal issues, but I shall ensure that we can return to them in due course.

Philip Hammond: I am grateful to the Minister for his indulgence in allowing me to make one final point in this rally.
 He asked a few moments ago whether I thought that patients should not be seen at walk-in centres if they did not want to disclose their identities. I was not suggesting that; I was asking the Minister to acknowledge an inconsistency. We all believe that, in principle, continuity of care is a positive thing, and the amendment seeks to achieve that for out-of-hours services. Does the Minister accept that, by creating walk-in centres, with all their convenience, the Government have for the first time allowed patients access to the NHS free at the point of use without that consultation having to be entered in their medical records? 
 For the first time in the family practitioner service, we will allow patients selectively to edit their on-going definitive medical history. As in the example given by the hon. Member for Isle of Wight (Dr. Brand), patients already do that to ensure that information that may be embarrassing or inconvenient or that may affect their insurance ratings is excluded from their medical history.

John Denham: I am not sure that that is the case. For example, those who go to accident and emergency departments and do not reveal their real identity are not turned away. There are many ways in which patients can do that. It is generally undesirable, although the hon. Gentleman mentioned circumstances in which it might be necessary. For example, in the tradition of genito-urinary medicine clinics, confidentiality is respected. It has always been possible to gain access to the NHS without identifying oneself. Perhaps we can return to that matter later.

Desmond Swayne: My hon. Friend the Member for Runnymede and Weybridge has drawn our attention to a key point that goes to the heart of our concern about the fragmentation of access to the NHS.

Hilton Dawson: Does the hon. Gentleman recognise that in drawing attention to what he calls fragmentation, he overlooks the excellence of NHS Direct? He should note the comments of Mrs. Jean Jones of Pickthorn close, Lancaster, who spoke of the tremendous benefit that she derived from NHS Direct on new year's day 2001. It gave her excellent, comforting, reassuring advice when medical services were not available to her husband.

Desmond Swayne: I could detain the Committee for some time, Mr. Maxton, but you have informed me in a note that there will be a stand part debate, so I shall confine myself to the narrow subject of the amendment on out-of-hours access. I am reassured to learn from the Minister that what we would like included in the Bill, by way of amendment No. 169, will be dealt with in regulations.
 I am not entirely sure that I understood the compromise that the Minister was outlining with respect to amendment No. 168. Am I right in thinking that he was suggesting a regional structure?

John Denham: To use an example from my locality, Southampton and South West Hampshire health authority might decide to accept the judgment of Portsmouth and South East Hampshire health authority in accrediting a service that was offered across both health authority areas. However, there would not be a requirement on the Southampton and South West Hampshire health authority to accept another health authority's judgment. That allows for cases in which it is thought that the quality of service might vary between areas.

Desmond Swayne: I now understand the Minister. That leaves us with reservations about the bureaucratic hurdles that a provider might have to negotiate if the health authorities were not minded to accept one another's accreditations. However, seeing the clock, I beg to ask leave to withdraw the amendment.
 Amendment, by leave, withdrawn.

John Maxton: Order. I wonder whether it would be for the convenience of the Committee if I mentioned that while, as Chairman, I am reasonably tolerant of amendments if they help the debate, in the previous debate my tolerance was stretched a little.
 Question proposed, That the clause stand part of the Bill. 
 Mr. Swayne: We welcome the principle of the clause. It is appropriate and desirable that a high standard of out-of-hours care should be available throughout the country. I am sure that all hon. Members will be aware of the need for that from their postbags and constituency case work. The health service ombudsman has drawn attention to existing problems. 
 Some concerns remain, however. The first is that the clause has resource implications for the administration and scrutiny of the accreditation process. What is the Minister's estimate of the effort and cost that health authorities will have to face with the new duty? 
 I received a brief from the Royal College of Nursing that detailed a concern pertinent to the clause, although it also affects a number of others. It sought assurances that the new accreditation conditions will not exclude nurse-led practices under the new personal medical services dispensation. Some nurse-led practices employ GPs, but the RCN fears that, because nurses cannot act as principals, they will be excluded from acquiring accreditation under the clause. Will the Minister deal with that concern? 
 We understand that, by 2004, a single phone call to NHS Direct will be a one-stop gateway for out-of-hours access to health care, with NHS Direct passing on the calls to the GP or the out-of-hours provider. Our concern is that that should not be the only gateway; it should be a one-stop shop or gateway but not the only one. 
 The independent report ``Raising New Standards for Patients -New Partnerships in Out-of-Hours Care'' proposes, in recommendation 7: 
 Service level agreements incorporating all the Quality Standards should be established, between NHS Direct and all providers of out-of-hours services. 
We are concerned that these regulations will be used to push all out-of-hours providers into accepting NHS Direct as the only gateway to their services.

Simon Burns: Has my hon. Friend ever rung NHS Direct? Unlike the hon. Member for Lancaster and Wyre (Mr. Dawson), I phoned on new year's day 2001 to get some advice on a child's health but, after 25 minutes of waiting to get through, I had to give up.

Desmond Swayne: I have only rung NHS Direct when I have been prompted to do so by constituents who have complained to me about the service. I always use pharmacists rather than the assistance that can be had over the phone from medical professionals, for precisely the reasons to which my hon. Friend drew attention.
 We fear that these regulations will push us towards a situation in which someone wanting to access any out-of-hours provision must do so via NHS Direct.

Philip Hammond: Although my hon. Friend has not stated this explicitly, he knows well that pilots are being considered in which access to the 999 ambulance service is also obtained via NHS Direct. The experience of my hon. Friend the Member for West Chelmsford (Mr. Burns) could be alarming in that context.

Desmond Swayne: I am aware of that, and the prospect is most alarming. We have the same concern with those pilots as we have with these regulations: that they will be used as a means of enforcing the provider to allow access to his service only through NHS Direct.

Lorna Fitzsimons: Whatever the experiences of the hon. Gentleman and his colleagues, will he also accept that I am deluged with complaints about surgeries that leave inadequate answer phone messages? In some cases, the contact number for an emergency doctor is cut off halfway through, and no information is given about when the surgery will next be open or about any service alternatives. That leaves the person no choice but to go to an accident and emergency department or to contact NHS Direct.
 We are lucky enough in my area to be able to access NHS Direct. It is a safeguard for many people who find themselves in the same situation as the hon. Member for West Chelmsford when he had to phone to get advice about a sick child. I have used the service and found it invaluable when the ordinary surgery has let me down.

Desmond Swayne: I should be interested to know how long the hon. Lady waited to get through. She draws attention to a legitimate concern in saying that there needs to be a safety valve. The problems that she has highlighted should be rectified by the regulations that we have discussed, so that a high quality standard of provision is assured. Our fear is that NHS Direct will become the only means by which out-of-hours services can be accessed. We do not believe that it is proper to move to such a situation until the case for NHS Direct has become much sounder than it is at the moment. The jury is still out.
 My hon. Friends have already drawn attention to the problems that many people perceive with NHS Direct. Only last year, the conference of the British Medical Association voted that the £80 million currently being spent on NHS Direct would be better spent on renovating their surgeries [Laughter.] I can understand there being a measure of self-interest among general practitioners, but those are the very people who must have confidence in that service. It would be improper of us to use these regulations to require them to make their out-of-hours services available only through NHS Direct before there is sufficient confidence in NHS Direct to bear the weight of that requirement.

Hilton Dawson: Does the hon. Gentleman accept that the experience of the present pilot project for NHS Direct is that, despite some initial scepticism from GPs, the project has been successful and has developed largely because of the co-operative attitudes of GPs and the medical profession?

Desmond Swayne: Experiences differ as, no doubt, the National Audit Office report will tell us. However, at the moment the jury is very much out. A snapshot survey of 500 calls to NHS Direct from 5 to 11 January last year showed that 33 per cent. of patients were advised to take care of themselves, 23 per cent. were told to go to their GP immediately, 18 per cent. were advised to see their GP as a routine visit and 6 per cent. were told to go to their hospital accident and emergency department, of which 2 per cent. were to be as emergencies. In addition, 18 per cent. were told to seek advice from another health professional or to get more information. Most of the calls involved young children and young women, with a low rate for older adults.
 The survey showed that almost half those who ring NHS Direct go to their GP as well. A call to the service costs the NHS £8. A visit to the GP costs £10.55, and one to an accident and emergency department £42. When a patient talks to NHS Direct and then goes to the doctor—as so many do—it costs a total of £18.55, so we are increasing the cost to the national health service by sending so many of the people who have rung NHS Direct to their doctors. They may as well have gone straight to the doctor and saved the additional cost.

Adrian Bailey: Does the hon. Gentleman acknowledge that many people phone NHS Direct for advice about whether they should go to the GP? When the advice is that there is no need to go to the GP, there is a potential saving to the NHS that should be incorporated in the figures.

Desmond Swayne: The answer to the hon. Gentleman is that very few of those who ring NHS Direct are saved that trouble, because so many subsequently visit their GP.

Philip Hammond: Labour Members are jumping up and down like Jack-in-the-boxes to extol the virtues of NHS Direct. The fact is that the Government have rolled out the programme without a robust evaluation of its success and cost effectiveness. Now, our best hope is that the National Audit Office will undertake a full investigation into NHS Direct and its cost effectiveness, and only after that will sensible decisions about its role be taken. Until then, neither Labour Members nor anyone else can make an effective evaluation of the part that NHS Direct plays in our health system.

Desmond Swayne: My hon. Friend is right and we are awaiting that investigation. It would not be acceptable if the regulations could create a situation in which the only out-of-hours access to the NHS was via NHS Direct, given that we are doubtful about the robustness of that organisation to deliver the service. My hon. Friend's point that there has been no evaluation of NHS Direct is accurate, although the figures that I quoted come from Sheffield university's evaluation of NHS Direct's first-wave sites, contained in the second interim report to the Department of Health, produced in February last year.

Philip Hammond: It was not robust.

Desmond Swayne: It may not have been robust, but it nevertheless drew attention to a significant number of problems. My hon. Friend is correct that we must await a more thorough examination. The medical profession is deeply concerned about the way in which NHS Direct has been rolled out without any proper evaluation hitherto. It is time that that evaluation was made. We should not accept regulations that create a situation in which all out-of-hours access is through NHS Direct when so many questions still pertain to that organisation.

Peter Brand: I do not want discussion on the clause to focus solely on NHS Direct. However, it is clearly an evolving service that is having problems during its evolution. Not only has it found it difficult to cope with capacity, but there have also been significant problems with the computer programmes on which the advice is based. It can take a long time to get hold of someone, and the assessment process by an NHS Direct assessor is very time consuming. Sometimes advice is also a little too direct. One of my wife's patients told her that NHS Direct had told the mother that the child had to be seen by a doctor within an hour. It is not the role of NHS Direct to dictate how a patient should be seen, or at least I do not believe that it should be. Those issues must be resolved in time.
 I worry that NHS Direct is a free service to GPs. In effect, GPs are being bribed into using NHS Direct because they are pragmatic people who will use a free service. However, it is not a free good and we must recognise that public money is spent on that service. Let us hope that it works out well. 
 My concern about the clause is that a health authority may be reluctant to sanction any other other-of-hours services as out-of-hours first-line-of-call access is free through NHS Direct. Would arrangements made by individual contractors—to have internal rotas, for example—also have to be approved by the health authority, or could those contractors retain their individual 24-hours-a-day responsibility? I was in a single-handed practice for about 15 years, and I was on call every night apart from Thursday, through a rota with colleagues. That worked well, except that one of my colleagues, who was not terribly reliable, put a message on the answer phone saying, ``If there are any problems, ring me at home''. 
 Such methods are no longer acceptable to most practitioners, and would not be to me now, because patients' attitudes have changed. That is perhaps part of increasing consumerism, which the Government have fuelled by raising patients' expectations that there should be access to just about anything, 24 hours a day. That issue needs to be addressed, but not in this debate.

Philip Hammond: The hon. Gentleman pursues an interesting line and might further ask the Minister whether the purpose of the clause is to approve providers of out-of-hours services, or whether the regulations under it are to be used to define the routes of access to those services by making it a condition of approval that a person's service is accessed in a certain way. That would run some of the risks that the hon. Gentleman has outlined.

Peter Brand: I am grateful for that intervention, which clarifies what I was intending to say. The clause gives the Secretary of State the power, through regulations, to determine how access is provided, irrespective of local traditions or of what has worked in the past.
 I do not oppose the clause, because I am a realist and I know that the world has moved on during the past 20 years. However, I would like an assurance from the Minister that the clause gives neither the Secretary of State nor health authorities powers of direction that could become unreasonable, such as the power to direct not in the interests of patient care but in the interests of administrative convenience, or even the power to shuffle responsibilities among different budgets.

John Denham: I shall start on that final point. The clear intention of the clause is to enable the setting of standards that providers will have to meet. The focus is on those standards; that should be a considerable reassurance to the Committee. Those standards will have to be met by all accredited providers, however their services may be organised. I do not find it acceptable to require a higher standard from one provider than from another. For example, the out-of-hours review proposed that 1 per cent. of clinical records should be continuously audited by a sampling method that would measure the standard of record keeping for each provider of out-of-hours services. We would not want the out-of-hours services of some patients to be subject to that regime, but not those of others. The out-of-hours review suggested the imposition of standards on aspects of telephone access, such as the percentage of calls engaged or abandoned and the time taken to answer, and on the way in which the triage system operates.
 Such standards should be available to patients in all parts of the country, irrespective of the way in which the service is provided. Our focus is on those standards. The out-of-hours review suggests measures that are directly related to patient services and patient outcomes rather than to particular organisational models. For example, time limits for home visits in the case of an emergency should be subject to quality standards. 
 It is important that record keeping and auditing should be of a consistent standard throughout the country, however the provider organises its service.

Philip Hammond: Is the Minister saying that he will not use the regulations under the clause to define certain methods of access only to out-of-hours providers?

John Denham: We have no intention of using the regulations to require every patient to follow a particular procedure—as they are currently drafted, I am unsure whether we could use them in that way. However, I believe that patients will find it convenient to have to ring only one number to access advice and out-of-hours services. That service is already offered to between 2 and 3 million patients in England, as a result of the integration of NHS Direct with GP co-ops. Therefore, it is not just a fanciful concept. It already exists in large areas of west London, where the Harmoni co-op is integrated with NHS Direct. An increasing number of co-ops are integrating their services with NHS Direct. The situation will further improve as the latest triage software becomes available to the whole of NHS Direct and is integrated with out-of-hours services.
 An existing telephone line may be retained because, for example, a co-op may wish to offer that service to its patients; but I believe that most patients will prefer to have to remember only one number to access a wide range of services. 
 I assume that the Committee has not discussed in detail the principle of accreditation because it generally welcomes the proposals that underlie the clause, and that are described, in particular, in the out-of-hours review. Therefore, although I could discuss the clause in more detail, it might be satisfactory to deal only with the issues raised in the debate. 
 I am unsure whether the hon. Member for New Forest, West was objecting to the concept of NHS Direct or to the idea that there should be accreditation and standards. I assume that he accepts the idea but does not like NHS Direct. 
 When we began to develop NHS Direct, the official Opposition used to jump up and down and say, ``We thought of it first.'' Now, just as its success is becoming apparent, they seem to have changed their tune. That is typical of their political judgment at the moment.

Philip Hammond: The Minister has rattled my cage. I reassert that my party thought of NHS Direct first; I think that our pilot scheme was in Wiltshire. We have consistently said that NHS Direct could play an important role in the overall delivery of health care services, but it must be properly evaluated before it is rolled out. Our objection is that the Government rolled out the pilot schemes nationwide without any robust study of the value for money and cost-effectiveness provided by the service. As the NHS budget is limited, that is an irresponsible way to proceed.

John Denham: I disagree. NHS Direct—which is clearly linked with the provision of out-of-hours services—is subject to continuous evaluation, and that evaluation is published. NHS Direct is also subject to a degree of clinical governance that is not practised in every part of the NHS. That is one of the great strengths of NHS Direct. Consultations are tape recorded, although the information contained on those recordings is confidential. Therefore, if a patient complains that he or she was told to do X, that can be checked. That would not be the case in almost any other consultation that may take place elsewhere in the health service, and it has enabled previous allegations to be substantiated.
 I want progress to be made with out-of-hours services, so that it becomes possible in every part of the country to access accredited out-of-hours services by ringing the NHS Direct number. At present, millions of patients already have that service. Other GP co-operatives would like to work with NHS Direct because they recognise the advantage of having NHS Direct provide a triage service. People working in other parts of the service want to see how it works in practice. That is why the implementation of the out-of-hours review is based on the development of exemplar projects over the coming years. 
 Those projects will demonstrate to GPs who may be uncertain about which course to take that the service is a cost-effective, patient-friendly and doctor-friendly way of proceeding. That will enable those services to achieve the necessary standards of accreditation and to offer a better service to patients. When we responded to the out-of-hours review, I made it clear that we wanted to proceed on that basis. By working with those who want to move in this direction at an early stage, we will be able to demonstrate to those who have doubts that this is the right direction.

Desmond Swayne: The Minister asked if I was opposed in principle to accreditation. In my opening remarks, I sought to make it absolutely clear that we are in favour of that. We support the principle behind the clause. Our concern is that the regulations might be used to enforce access to all out-of-hours services via NHS Direct, which we do not believe is yet sufficiently robust to bear that burden.

John Denham: I have dealt briefly with the strategy that we would prefer to follow in order to convince people, and I believe that we will achieve our objective.
 The resolution of practitioners at the BMA last year about investing £80 million in their premises provoked some amusement. At our last sitting, we discussed the investment of £8,000 million in the premises of GPs, so clearly we are meeting that aspiration of the medical profession. 
 Regarding nurse-led practices, the responsibility for out-of-hours provision clearly lies with the GP, as does the rest of the service. However, there is no bar to nurse-led practices—PMS practices—becoming accredited providers, provided that they meet the standards set out in the regulations.

Peter Brand: The Minister did not respond to my specific question about whether rotas for GPs who intend to retain 24-hour responsibility will be caught by the regulatory mechanism.

John Denham: I had intended to answer the hon. Gentleman's question. It does not matter whether the service is provided by rotas. If it is an out-of-hours service, it has to be accredited under the regulations. The quality of the service offered to the patient must be consistent.

Peter Brand: If a husband and wife team look after a practice population 90 per cent. of the time, will they have to apply for accreditation in order to have an arrangement about who gets up at night?

John Denham: The issue is whether someone delegates responsibility to another provider. If that is unclear, I will write to the hon. Gentleman.
 We must ensure that we have consistent standards across the service. That should be a part of any arrangements that are put into place. There will be some challenges to the traditional provider or practice, but if there is no delegation—the individual is offering a 24-hour service as stated in his or her contract—there will be no accreditation requirement. 
 Question put and agreed to. 
 Clause 21 ordered to stand part of the Bill. 
 Further consideration adjourned.—[Mr. Jamieson.] 
 Adjourned accordingly at twenty-four minutes past Eleven o'clock till this day at half-past Two o'clock.